Meningiomas presenting with paranasal sinus involvement

Extracranial paranasal spread of meningiomas is uncommon. We describe the management of four cases, all of which first presented to an oto-rhino-laryngologist for an opinion. We suggest that greater use of modern imaging techniques could lead to earlier diagnosis. The natural history of extracranial spread is relatively benign but the management of regrowth of residual disease is difficult. We therefore suggest radical surgery in the first instance provided that the patients general health and configuration of the tumour allow.     

Acute Cholecystitis and Severe Ischemic Cardiac Disease: Is Laparoscopy Indicated?

BACKGROUND AND OBJECTIVES: Laparoscopy in patients with poor cardiac function has been the subject of controversy and is considered by many surgeons a relative contraindication. METHODS: We report the case of a patient who presented with acute cholecystitis and choledocholithiasis concurrent with unstable angina. Our experience in laparoscopic management of patients with calculous biliary disease and severe coronary artery disease is examined. RESULTS: The patient was managed by coronary angioplasty and stenting immediately followed by laparoscopic cholecystectomy and common bile duct exploration under close invasive hemodynamic monitoring and low-pressure pneumoperitoneum. Between 1996 and 2001, 39 patients with coronary artery disease and an ASA class of III or IV underwent laparoscopic cholecystectomy. Eight of these patients (20.5%) had common bile duct stones necessitating laparoscopic common bile duct exploration. No conversions were necessary, and no major morbidity or mortalities occurred. CONCLUSIONS: Laparoscopic cholecystectomy and common bile duct exploration can be safely performed in patients with severe ischemic cardiac disease under close hemodynamic monitoring and a low-pressure pneumoperitoneum (10 to 12 mm Hg).     

HLA-DR expression in macaque neuroendothelial cells in vitro and during SIV encephalitis

HLA-DR expression in neuroendothelial cells (NEC) was studied during the course of SIV encephalitis in rhesus monkeys. HLA-DR determinants were detected on NEC in monkeys with SIV encephalitis, but not in control animals. In situ hybridization with an SIV probe indicated that HLA-DR expression was not a consequence of SIV replication within NEC. Cultured rhesus NEC stimulated with gamma interferon expressed HLA-DR to a higher degree than cultured brain fibroblasts or astrocytes. These data support the contention that NEC participate in retrovirus-induced inflammation and autoimmunity within the central nervous system.     

Genetic determinants of statin intolerance

Background  

Statin-related skeletal muscle disorders range from benign myalgias – such as non-specific muscle aches or joint pains without elevated serum creatinine kinase (CK) concentration – to true myositis with >10-fold elevation of serum CK, to rhabdomyolysis and myoglobinuria. The genetic basis of statin-related muscle disorders is largely unknown. Because mutations in the COQ2 gene are associated with severe inherited myopathy, we hypothesized that common, mild genetic variation in COQ2 would be associated with inter-individual variation in statin intolerance. We studied 133 subjects who developed myopathy on statin monotherapy and 158 matched controls who tolerated statins without incident or complaint.     

Safety and efficacy of radiofrequency ablation of brain: a potentially minimally invasive treatment for brain tumours.

INTRODUCTION: Cerebral metastases are associated with a very poor prognosis. The best survival results are seen after surgical resection. However this involves a relatively invasive procedure and many patients are not suitable for surgical resection. We have evaluated the safety and efficacy of radiofrequency ablation of the brain in a sheep model. METHODS: We produced ablations of 1 - 3 cm diameter in the brain of sheep using the RITA starburst XL probe and RITA 1500 generator. We varied the time of RF application between 1 minute and 5 minutes and observed the animals for between 24 hours and 3 weeks for short-term and long-term effects and measured the intracranial pressure (ICP) in 2 animals following RFA. RESULTS: A total of 8 ablations were produced in 8 sheep. There was no change in the ICP measurements and there were no neurological complications in the 5 sheep with superficial ablation of up to 2 cm. Three sheep failed to regain consciousness due to large ablations near the brain stem and cerebellum. The sizes of the ablations were confirmed on necropsy and there was no other evidence of damage to the surrounding brain. Satisfactory ablation of brain was achieved at 70 degrees C and an ablation time as short as 3 minutes produced a 1.5 - 2.0 cm diameter of ablation. CONCLUSION: Cerebral RFA is a relatively safe and effective technique capable of producing a predictable ablation with no damage to surrounding brain. The potential of this technique requires further evaluation but likely advantages include the ability to treat multiple tumours and perform repeated treatment with a minimally invasive approach.     

Right superficial femoral artery to superior vena cava graft using a polytetrafluroethylene graft: a new technique in a complicated dialysis access patient.

Sir, The expansion of haemodialysis includes older patients withcomorbidities, poor quality vessels, unsuitable for transplantationor peritoneal dialysis. Vascular access complications accountfor 20% of hospital admissions [1]. With exhausted sites inupper extremities, unusual sites for arteriovenous grafts formationare used [2]. The     

Effects of Increasing Gestation,Cortisol and Maternal Undernutrition on Hypothalamic Neuropeptide Y Expression in the Sheep Fetus

We have characterized the localization and the ontogenetic changes in Neuropeptide tyrosine (NPY) before birth and investigated the regulation of NPY expression by cortisol and undernutrition in the fetal sheep hypothalamus during late gestation. Using immunohistochemistry, we have identified NPY-containing neurons in the infundibular nucleus and the internal layer of the median eminence in fetal hypothalami collected between 110 and 147 days gestation. NPY projections were also present in the paraventricular nucleus (PVN) of fetal hypothalami at all ages between 110 days gestation and term. There was a significant increase in the amount of immunoreactive NPY/g hypothalamus between 87 and 113 days and 131–140 days gestation and a further significant increase after 141 days gestation. The total hypothalamic content of immunoreactive NPY increased significantly between 87 and 113 days and 141–145 days gestation. The levels of NPY mRNA: 18S rRNA in the mediobasal region of the fetal hypothalamus were significantly higher at 145–146 days gestation than at any earlier gestational age between 116 and 141 days gestation. Cortisol (2.5–3.0 mg/24 h) was infused intrafetally between 109 and 116 days gestation. The ratio of NPY mRNA: 18s rRNA in the mediobasal region of the fetal hypothalamus was significantly higher in the cortisol-infused group when compared with the saline-infused control group at 116 days gestation. Maternal, and hence fetal undernutrition, was induced between 110 and 146 days gestation. At 145–146 days gestation the ratio of NPY mRNA: 18S rRNA in the mediobasal region of the fetal hypothalamus was significantly higher in the undernutrition group when compared with control animals. We have therefore demonstrated that NPY is present in the hypothalamus of the sheep fetus before birth and that hypothalamic NPY content and NPY mRNA increase before delivery. We have also found that glucocorticoids and undernutrition stimulate increases in NPY mRNA levels in the hypothalamus before birth.     

Coexistence of Neoplasia and Cortical Dysplasia in Patients Presenting with Seizures

Summary: Tumors and cortical dysplasia are associated with epilepsy, but few studies have examined the coexistence of neoplasia and dysplasia in these patients. We studied 13 patients (age 4–29 years) with recurrent seizures of 1 month to 21-year' duration (median 72 months). Ten patients were aged <21 years. Imaging studies localized the lesion to the temporal lobe (10 patients), parietal lobe (2 patients), and frontal lobe (1 patient). Tumors included ganglioglioma (8 patients), dysembryoplastic neuroepithelial tumor (DNT) (3 patients), and low-grade as- trocytoma (2 patients). Cortical dysplasia, including atypical aggregates of neurons (6 patients), multifocal loss of the cortical laminar architecture (7 patients), and neurons in the molecular layer of the cortex (3 patients) were observed near but separate from the tumor. Coexistence of certain tumors with cortical dysplasia, most frequently observed in the pediatric population, suggests a hamar-tomatous/dysplastic nature of the neoplasms.